Thursday, July 31, 2008

Online info has patients doubting doctors, survey finds: " NEW YORK - A new survey reveals that 85.6 million U.S. adults have doubted the opinion of their doctors or other medical professionals when it conflicts with information found online. That number represents about 38 percent of the population."

If doctors provided reliable medical information online themselves, then there would be no reason for adults to doubt them. It's because doctors do not take a proactive approach towards online patient education, that many of these conflicts arise. The danger is that some people will end up putting their faith in a website run by a quack, rather than a reputed doctor !

NB - I find it hard to understand how they came up with exact number ! I'd doubt it's accuracy !

Modern medicine is full of activity - scans, tests and surgery. TV serials like ER popularise this image of an "action-oriented" doctor who "fights disease" by "battling it". These can be dangerous metaphors !

All diseases have a natural history and many will get better by themselves. Others do not require any "treatment" or management - for example, localised prostatic cancer in older men.These are best managed by " watchful waiting" or " masterly inactivity". This was a skill older doctors were very good at, because they had very little to offer in the form of intervention - and were wise enough to realise this. " Don't just do something - sit there ( and hold the patient's hand !)" was extremely good advise.

Unfortunately, as medical technology has evolved, doctors have become overconfident . They have acquired a cocksure attittude, and are willing to do battle on the patient's behalf, to fix any problems their machines can find.

An extremely good example of this is endometriosis. This has rightly been called " an engima wrapped inside a riddle" because we understand so little about it. The problem is that our understanding still remains equally poor , but because we can make a diagnosis much more accurately ( with ultrasound scans, blood tests and laparoscopy), many doctors feel that we can "treat" much more effectively. Since many infertile women will have minimal endometriosis( and we don't know yet whether this is coincidental - or even if the infertility causes the endometriosis rather than the other way around!) Sometimes the treatment causes more harm than good - but we don't even know this as yet.

We are now seeing an epidemic of overtesting and overtreatment. There are many reasons for this. Firstly, the technology has become much better. The newer scanning machines can pick up small abnormalities - and once these are documented and reported, they are grist for the medical mill.

Secondly, there is much more money to be made in treating that in "leaving well alone". Not only do medical equipment manufacturers push their wares, doctors are very happy to exercise their surgical skills - because this is what they are good at !

Senior doctor have the maturity to let sleeping dogs lie - and understand that you cannot make an asymptomatic patient better. They realise that not everything needs to be "treated" and that sometimes the cure is worse than the disease.

Unfortunately, it's the "trigger-happy" doctors ( whose trips to conferences are often paid for by medical equipment manufacturers ) who are very aggressive in promoting their "neo-treatment options". Since these are "new" toys, many doctors are very happy to play with them , which means they have a very willing audience. Few people are willing to listen to the older, senior fogeys - who maybe more mature, but don't have anything very interesting to say !

Infertile patients will often get an ultrasound scan done to check their pelvic anatomy. Many of them will have small fibroids; or ovarian cysts, which the radiologist will duly report. The tragedy is that doctors will then use this as a pretext to operate on these patients to "correct" these abnormalities.

The truth is that most women ( including fertile women) will have small cysts and fibroids. These are extremely common benign tumours, which do not cause any problem. The trouble is that modern imaging techniques have become so "good", that they can pick up all these minor findings. This is where the problem starts. Patients are not sophisticated enough to realise that these are of no clinical importance. Because they are noted and reported, they start panicking when they read the report. Unscrupulous doctors then take advantage of this, and suggest "minor surgery" to correct this problem. This is the second problem. Because modern surgical techniques have become so "good", most of these can be removed by "minimally invasive surgery". Since it's minor surgery, patients are quite happy to agree to the intervention. Not only does this kind of surgery do no good, it causes the patient to lose time, money and energy - and when the surgery fails to result in a baby, they end up losing confidence in doctors and the medical profession. Many doctors, in order to increase their workload and patient throughput, will often have a "tie-up" with a friendly radiologist, who is encouraged to report these minor findings, so that they can "correct " them !

Good doctors are conservative - and will not advise unnecessary surgical intervention. Sometimes, remember that "less is more" !

Wednesday, July 30, 2008

Digital HealthCare - Walmart style : "Agwunobi said he knew health care had some problems, but had no idea how badly the system was broken until he took the Wal-Mart job last September and saw how efficient a major retail operation could be.

“Retail has gone through a transformation that is beginning to happen in health and health care,” Agwunobi said. For example, bar coding, which has been around for about 35 years, is pretty much the norm in retail environments. But the same technology is in limited use for tracking medications and supplies in hospitals even today.

“Success or failure is dependent upon whether you keep up with your customers or fall behind. Health care fell behind,” Agwunobi said.

“The bottom line is we think this notion of the personal health record is about the customer,” Agwunobi said, and that the customer will come to realize this. “When we give it to her, we will find that she is a better owner than we have ever been.”"

Monday, July 28, 2008

IVF News - UK survey reveals that three-quarters of infertile patients would consider treatment abroad: "An overwhelming majority of infertility patients in the UK said they would contemplate travelling abroad for fertility treatment, according to the first comprehensive study on the strength and motivations behind the fertility tourism industry. Among the 339 infertile patients who responded to an online poll conducted by Infertility Network UK, 76 per cent stated they would be willing to seek fertility treatment outside the UK with 70 per cent citing their reasons would be to avoid higher costs and long wait-lists at UK clinics. Infertility Network UK performed the survey for this year's National Infertility Day on Saturday, 19 July 2008, when it announced its findings at a conference in central London.

Other popular reasons provided by the patients for why they might prefer to receive fertility treatment abroad were high success rates (61 per cent) and the greater availability of donor eggs and sperm (54 per cent). The UK has suffered a decline in the number of egg and sperm donors since removing donor anonymity by law in 2005."

Saturday, July 26, 2008

I often ask my patients to prepare a one-page summary of their medical history. I provide them with a simple framework to help them structure this, so they do not forget anything important. Not only does this discipline allow them to make sense of their medical records , it also helps them to ask questions. It helps me to ensure that the records are complete; that important information has not been inadvertently omitted; and that patients have a sound understanding of their past treatment and future options.

For some patients, I even invite them to formulate a treatment plan and to write their own prescriptions - especially when they are doing a second IVF cycle . This allows me to confirm that they have understood what is happening to them - and if they make any errors, this is a teaching moment which I can use to clarify doubts and confusion.

It's quite sobering to find out that even though I think I have done a great job with explaining the treatment options, patients sometimes have a completely different take on their problem. By listening to their inputs, I learn how to do a better job of counselling and educating them.

Infertile couples will often find that they cannot agree on a common course of action. The wife may want to do the fifth IVF cycle, while the husband would rather adopt. It's very hard to come to a consensus - and they often end up compromising, which means they both are unhappy with the decision they finally reach, because it's not their first choice. They both end up as losers.

I remind them that they are on the same side, even if they find they are not on the same page. They need to use win-win negotiation tools, so they are both happy. This can mean sitting down and plotting a course of action, which both are comfortable with. For example, the husband can agree to the fifth IVF cycle, if the wife agrees that this will be their final cycle, and they will consider adoption if this fails.

Of course, hearts are fickle and they can change their minds - but at least this type of planning gives them a path they can both follow together.

Patients need to weigh multiple factors when making a decision as to which treatment to select. These include : costs, risks, medical expertise, personal beliefs, social pressures. This is why medical decision making can be so hard. This is especially true for infertile couples, because treatment is elective - and there are so many choices.

Unfortunately, many get confused and don't know what to do next. They either get analysis-paralysis; or allow their doctor to make all the decisions, since he is the "expert".

Both these options are not optimal, because a doctor cannot read your mind ! I find that the following guide helps many of my patients to think through their options, so they can make a decision which gives them peace of mind.

The first step is to use your head. You need to do your research and find information so you can make a list of all your options . This list should be mutually exclusive and completely exhaustive. This should be done objectively , so don't make any judgments at this stage. It can help to pretend that you a compiling a list for a friend; and your only criterion is that the list should be as complete as possible. The doctor can be very helpful at this stage, in providing more information about the options; and their costs, risks and benefits.

There are quite a few problems with this step of gathering information. You may have too little - for example, if your doctor does not provide you with a copy of your medical records, so you don't have the data you need. Conversely, you may have too much - for example, if you do an uncritical google search. The information quality may be poor - and a lot of it maybe unreliable or outdated. Sometimes the information you unearth maybe contradictory - leading to even more confusion ! The good news is that it's possible to get good quality information if you are willing to be paitient ; are willing to learn; and to be critical.

The second step is to then use your heart. If you had no limitations, then which option would you select as the best choice ? The second best ? You need to rank your options, according to your personal preferences. Remember that you are using your heart, and you do not need to justify any of your choices - just follow your gut feelings !

I have often seen that two patients, when presented with exactly the same information, come to diametrically opposite conclusions ! This is because they have followed their heart - and everyone's heart is unique. It's fine to use prayer - or even tools such as astrology ( which defy logic) in this step.

The final step is to then combine both logic and emotions, and work out the logistics of what is practical, possible and feasible.

This decision making matrix will allow you to explore all options systematically, so you don't get confused and can follow the "path of least regret". This way you have peace of mind you did your best, no matter what the outcome ( which will always be uncertain in medicine !)

Friday, July 25, 2008

This is a guest entry from a "virtual patient" from Australia. I believe that doctors will never be able to improve their services until enlightened patients provide us with feedback so that we can meet their expectations. Patients need to tell doctors " what I want " , so that good doctors can try to do so. Ms Berggren is my ideal "dream patient" - and patients like her can help to improve healthcare services - if doctors are willing to listen.

" Pieces to the puzzle

A.Introductory Sessions

There is so much information to (a) digest and (b) sort out and keep what relates to you.

In the beginning I would have group sessions for IVF beginners that run in the evening for maybe 45 minutes that go through some of the following:

(a)Statistics

Every doctor I have met seems very comfortable and confident speaking to this topic.Further the backdrop of statistics sets up the framework for your risk – liability – safety net.At any stage you can point to the statistics to manage expectations.I think every one going through the process needs to be ingrained in the thinking that there are no guarantees but I may be able to:

(i)take the fertility drugs,

(ii)adopt supportive treatments,

(iii)change aspects of my lifestyle

to give myself the best chance overcoming the statistics;

(b)The Drugs

I think the women willingly injecting themselves deserve to have the simplest understanding of what each of the drugs do and why we should take them.While I have been provided instructions about refrigerating my drugs, which ones to take and what time to take them, I have no understanding of why they are used.

(c)Strategic Alliances with Other Professionals

It would be great if IVF clinics had strategic alliances with professionals practicing supportive therapies, such as acupuncture, natural therapy or yoga.In an ideal clinic you would be able to see any or all of these people right there in the same practice.That way you would get complete consistency in the message.Right now for example I have to take the scant information that I get from the nurses at the IVF clinic and relay it back to my acupuncturist so he can try and practice acupuncture to support the information I provide him.The risk of course is that I am relaying the information incorrectly.In a clinic where all these services were offered under the one roof, the patient would be assured of a collaborative approach to resolving infertility.

(d)Changing your lifestyle

I did ask the question at my first IVF appointment if there was anything I could do or eat to enhance my chances of growing healthy eggs.And the answer was there was nothing I could do other than stay thin.I have since come to find out there is a lot I can do, such as increase my intake of vegetables, wheatgrass, folic acid tablets, no coffee .. and of course DHEA.Again I appreciate that none of these provide guarantees but my goal is to give myself the best chance and perhaps the combination of these factors will assist that goal.I believe women should be provided a quick snapshot of ways we might change our lifestyle to become healthier and as a by-product grow more eggs and healthier ones.

(e)Acronyms

There also needs to be a better explanation somewhere of all the acronyms involved in this process.Your explanation on your website of FSH was excellent but that is only one acronym and there are many more to understand.I have found a couple of lists of what the acronyms stand for but without an understanding of why they are important I am only half way to informing myself about things I can do better.

B.Getting ready by yourself – things you can do on your own

Some patients have the capacity and desire to monitor their own blood tests and should be given the information so that they can do this and have a basic understanding of what’s going on in their bodies.Every time I have a scan I am always 2 steps ahead of the ultrasound scan technician because I have read everything I possibly can about the different scenarios that could eventuate from the number of follicles they find and the size.

I don’t think that every woman wants to be as informed but for those that do I think they should be given the tools to start being able to keep a meaningful record of their blood tests and they should be told when the correct day to do these tests are.

Someone like me wants to know all the blood tests I can do and have the tolls to be able to interpret the results in a simple fashion.The problem is I don’t know what are the top 5 blood tests to do and ask for and certainly no-one here will tell me.

I have found a useful website that has provided me with a lot of information about DHEA and growing follicles.On the website, you will see that one of its champions has set up a protocol for monitoring her blood levels and the number of follicles and size etc.There is no option for me to do this where I live.I have enough trouble getting my FSH checked every month let alone getting a specialist to check on my follicles every month.If I could I would have saved a lot of money in not proceeding on my failed attempts because the chances of success were not high enough to warrant the cost.

At my work, I am part of a team of 12 full time lawyers that services a company of 10,000 employees.Resourcing is always a challenge.One of the things we do to try and overcome first level questions and issues is to make the lawyers product champions.I am theoretically supposed to know answers to questions about contracting for a certain type of product, another lawyer is responsible for data products etc.

In an ideal clinic, you may wish to have issues champions, first level nursing staff or other staff that don’t have to be doctors but know everything there is to know about DHEA or follicles and can explain in basic terms what an antral follicle is as distinct from a regular one and how much they grow a day.Each of these issues champions becomes an expert in their field but is accessible (perhaps by email) and empathetic to problems from everyday people like me.The most important thing about the issues champions is that they will get back to you with an answer and if they don’t know the answer they will find you someone that does.

At the end of the day, what I have found with this process if that there are women like me who are information junkies on what we can do to help ourselves (and as a value add help the success rate of the IVF clinic we attend).The thing is though we are starved because of the way medicine in this area appears to be practiced.The doctors aren’t doing anything wrong but it’s like any customer service related industry, customers are getting more demanding and wanting more information about the product they are buying.

Indian doctors are often world leaders, and I think there are multiple reasons for this.

Most US doctors have a very rigid mind-set. They feel the world ends at the US borders. They have a "not-invented-here" mentality, because they feel that the US is the world leader; and that anything which originates from outside is inferior or not as good. Most US doctors will only trust what other US doctors say - and will often disregard the opinion of doctors in other countries, because they feel they are the best. I can understand this attitude, which is a hangover of the post World War 2 days when the US was the world leader in health care services and medical research. However, this attitude is obsolete in this day and age.

Indian doctors, on the other hand, are forced to be flexible right from their medical school days. All the medical text books are in English and in earlier days, all the standard medical text books were published in the US and the UK. Because they were not written for Indian conditions, Indian patients or Indian diseases, Indian doctors were forced to modify what they read and apply it to their own patients, so they did not become dogmatic ; and learned to trust their clinical senses.

Also, since we studied from both US authors and UK authors ( who often said diametrically opposite things), we developed a flexible world view, and learned to factor in the fact that there can be multiple opinions in medicine - all of which could be correct, depending upon the clinical circumstances.

Since India was ( and is !) a developing country, we often had limited access to lab tests and high technology imaging machines. This meant we had to depend upon our clinical acumen, which we polished to a high degree. Since India has such a dense population, there was never a shortage of patients to learn from !

Indian patients will often follow traditional Indian medical treatments ( such as ayurveda) while taking treatment - so that we learned to accept alternative medical systems - and to incorporate their good points when practising holistic medicine.

Finally, Indian doctors benefit from having a good bedside manner, because Indian religions( such as Hinduism and Buddhism) preach respect for others and a belief in karma, which inculcate an attitude of kindness and service.

Thursday, July 24, 2008

As an IVF specialist, I often cringe when I see what other infertility specialists do when they see patients.

Some common sins are:

1. Letting an assistant take the history, so the "expert" only spends a few minutes formulating the treatment plan. This is not a good idea, because taking a history is a great opportunity for the doctor to establish a personal rapport with the patient. Very busy doctors just don't have the time to do this, and they often delegate this key task to an assistant. This often means that patients do not get a chance to establish a relationship with their doctor.2. The "expert" only see the patient on the first visit, at which time they he is on his best behaviour, because he is trying to convince the patient to come to him for treatment. After the first visit, the patient never gets to see the "specialist" again - and has to make do by talking to nurses and assistants.3. Overtesting. Many clinics will routinely perform a "laundry list" of tests and investigations for all comers. This is bad medicine, because one size can never fit all. All this overtesting leads to additional problems such as overtreatment for unimportant findings, which are of no clinical importance. Not only are some of these "exotic" tests ( such as immune testing or tests for NK cells ) very expensive, their results are impossible to interpret, because they have never been validated. This type of testing adds to the aura of expertise ( because these are "new and specialised" tests which have never been done before !). Unfortunately, all they end up doing is wasting time, money and energy.4. Lack of transparency. Many clinics keep all the medical records; and do not share data or information with the patient. Not only is this very disrespectful, it's downright illegal, because patients have a right to their own medical records. Clinics do this in order to be able to "hold on" to their patients.

How can specialists get away with such behaviour ?

The commonest reason is because patients are intimidated and do not dare to ask questions. Because they are desperate, they put all their hopes on the doctor's expertise, and do not want to "rock the boat" by complaining or asking questions ! This leads to a vicious cycle, and because experts can get away with it, they continue doing so ( because this saves them a lot of time and allows them to maximise their throughput and their income).

* How do I find out if this procedure is covered by my insurance? * Who should I go see for this condition? * How do I get there? * What can people who have had this condition tell me about what it’s like to live with it?

The list of questions is virtually endless. The point is that information therapy refers to getting good information to people for whatever the consumer needs for his or her well-being and health/health care-related decision making."

Patients want much more information than doctors realise. And since most doctors feel their job is to provide only medical information about the disease, lots of questions go unanswered. In fact, the truth is that often doctors don't even know the answers to many of these questions ( for example, which is the cheapest brand of a particular drug). Patients want - and deserve - a single stop service which will fulfill all their needs, which is why specialty clinics, which provide all services about a particular problem under one roof ( such as IVF clinics) do so well.

Online Groups Supplement, but Don't Replace, Doctors: " In one of the earliest studies of e-patients who were members of an online support community, developer Bill Kelly and I surveyed 191 active members of a family of online support communities, which have since become a part of WebMD. Most of our respondents were seriously ill patients dealing with conditions like breast cancer, prostate cancer, ovarian cancer, and hepatitis C. We asked them to tell us which of the following three resources-their specialist physicians, their primary care physicians, or their online support groups-they would rate most highly in of the following categories:

Best in-depth information on my condition

Best practical knowledge of my condition

Best technical knowledge of my condition

Best for helping me find other medical resources

Best in helping to diagnose my problem correctly

Best in helping and advising on management after diagnosis

Most compassion and empathy

Best in helping with emotional issues

Best in helping with issues of death and dying

Most convenient

Most cost-effective

Most likely to be there for me in the long run

Online groups ranked significantly higher than either generalists or specialists for convenience, cost-effectiveness, emotional support, compassion/empathy, help in dealing with death and dying, medical referrals, practical coping tips, in-depth information and "most likely to be there for me in the long run." By a narrow margin, online health communities were also rated as the best source of technical medical knowledge. Specialist physicians were rated highest for help in diagnosing a condition correctly and for help in managing a condition after diagnosis.

To say that these results surprised us would be an understatement. We were stunned, even dumbfounded. Clearly the value of these groups, as perceived by the patients, was substantially greater than most health professionals had realized. Yet it appeared that online groups had relatively little to offer in some areas (e.g., the process of diagnosis). Doctors' abilities to advise patients on an ongoing treatment plan were also highly valued, as were their technical knowledge and their capacity for support and empathy. In fact, it appeared that doctors were best at what the groups were worst at, and vice versa. We concluded that the combination of a good doctor and a good support group might offer e-patients the best of all possible worlds."

The trick is to know which resource to use for what ! Smart patients know that while most doctors are great at making a diagnosis, they are often not the best source of emotional support !

Is the news media doing a good job of reporting on new treatments, tests, products, and procedures? Ray Moynihan and colleagues analyzed how often news stories quantified the costs, benefits, and harms of the interventions being discussed, and how often they reported potential conflicts of interest in story sources [1]. Of the 207 newspaper and television stories that they studied, 83 did not report the benefits of medications quantitatively, and of the 124 stories that did quantify the benefits of medications, only 18 presented both relative and absolute benefits. Of all the stories, 53% had no information about potential harms of the treatment, and 70% made no mention of treatment costs. "

The New Life of e-Patient Dave: "E-patients are “enabled, engaged, equipped and empowered.” Many snapshot examples here. The term was coined by Dr. Tom Ferguson, a true visionary, who saw in the 1990s how the Internet would transform healthcare by enabling patients to be active partners in their own care. He saw this long before widespread broadband came about, and before any of today's 'Health 2.0' tools existed. A true visionary."

The New Life of e-Patient Dave: Patient-Centered Primary Care: " I've recently been learning about a movement that started forty years ago: the 'medical home.' This is the idea that each of us should have a place we call home, medically. At first it was about keeping all your records in one place, but now it alludes to the reality that 40% of Americans don't even have a doctor's office they can call 'home.'

And the movement asserts that there are real, verifiable, measurable consequences of lacking that continuous care from a primary doctor who knows you."

Giesecke & Devrient will dispatch the new insurance cards to the insured with a rollout scheduled to start in January 2009.

The delivery scope includes optical and electronic personalization of the smart cards with individual data relating to the insured persons and their insurers.

The electronic health insurance card will initially store the policyholder's basic data, such as their name, address, date of birth and health insurance fund, along with details of insurance coverage and the person's status regarding supplementary charges.

The new smart card will first be used for electronic prescriptions and is already designed to store a qualified electronic signature that legally and technically will replace the need for users to sign by hand."

Sunday, July 20, 2008

Health Insurance companies using the internet intelligently : "Of all the healthcare organizations betting on the Internet today, perhaps none are as optimistic or committed to information technology as health plans. Chris Levan, chief information officer for BlueCross BlueShield of Tennessee, puts it succinctly when he states, “Everything we do has a Web component now.”

Internet applications for health plans span a wide spectrum, from sales and service to e-health initiatives. For example, health plans rely on the Internet to power provider connectivity for electronic claims and reimbursement transactions, support member management programs, enable more cost-effective and timely case review and utilization management, and more recently, to deliver personalized disease management programs in an effort to improve consumer health and lower costs."

Learn to Delegate Duties in Your Medical Practice : "If you're the owner or co-owner of your own medical practice, you may spend a lot of time worrying about the details of your business, from the billing and office décor to patients. But while staying involved in the day-to-day details may seem like a good route to quality control, it's really a good way to mess up your practice.

Here's why: As a physician, your training and experience make you well qualified for examining and treating patients. That training and experience means that your salary is among the highest in your office. And paying a $100,000-a-year staffer (that's you) to order supplies, take preoperative histories, give shots, send out bills, or haggle with HMOs doesn't make financial sense. Instead, you need to use less expensive staffers to take on duties that don't require your skill set, and save your time for doing what brings the real money into the practice: caring for patients and caring for them well."

APTA | Critical Times: The Patient as Health Care Consumer: "That need for a “desirable experience” goes right to the heart of health care consumerism. Patients and clients, after all, are consumers of health care. In one way or another, they pay for the services they receive. A visit to the clinic may be, first and foremost, about healing and wellness, but it is also a business transaction, and as such it's open to scrutiny by any patient/client with a critical eye."

Strategic Health Care Communications :: Experience Mapping : "If you want to see things through someone else’s eyes, you’ve got to put yourself in that person’s shoes. This old advice, when applied in a health care setting, is helping some hospitals find out what patients really think and feel about their health care experience. Hospitals are using the knowledge to tweak services and facilities to improve satisfaction and drive more business. It’s called “experience mapping."

The Healthcare Entrepreneur » Blog Archive » Lessons learned: The gas station attendant: " I immediately drew a parallel to what we do in the healthcare field as relates to customer service. Whether a doctor, dentist, physical therapist, or someone else in the field, we care for people - not windshields or cars. In doing so, we are able to reap the rewards of benefiting real people who, in most cases, are experiencing difficult times influenced by illness or injury. People don’t come to see us because we are cheap. They don’t come to see us because we’re on the way home (patients will drive an average of 5-7 miles to see us). They don’t come to see us because we’re a good alternative to a dinner and a movie. People come to see us because they need our help and they want us to care for them just as they would care for themselves (better in most cases)."

If patients want patient-centric medicine, they should provide feedback to their doctors, so their doctors can improve what they do ! If you don't like something in your doctor's clinic, have you told him about this ? Why not ? How can he improve if you don't express your displeasure ? Doctors need their patients' help to improve - and both complaints and compliments are welcome !

The Independent Urologist: How to start up a solo medical practice, deNovo!: "Medical practice is a small business just like any other. We may have issues that are unique to us, but the essence, obstacles, and, often, the solutions are the same for doctors, dry cleaners, pizza men, gardeners, chiropractors, dentists etc. In fact, a business entrepreneur friend gave me the best advice—the key to start up. What is key? The key is to define your ultimate goal, identify obstacles between you and your goal, and then to brainstorm solutions. List, actually list--on paper--obstacles on the left, goals on the right, and solutions in the middle. Do this, because it really, really works. Brainstorming relieves stress and enables you to focus, accomplish goals, and feel pride over reaching milestones. It is the first step in start-up."

How to Be a Healthy Visitor - The Patients Association: " The Patients Association Guide to Getting it Right. A hospital is not a hotel ! Patients are vulnerable to infection. Everyone in a hospital, especially visitors, is vital to keeping them as safe as possible for patients."

Lots of valuable tips on what you an do to help a patient in hospital !

Concierge Medicine and Carpetbaggers (Concierge Medicine Blog): "Few doctors would argue with the fact that it was the middleman — specifically the third-payers — who destroyed our medical system. Despite some good sales talk, these people did nothing to improve the quality of medical care that we delivered to our patients. To the contrary, they took a large portion of the healthcare dollar for their own profits and administrative fees, rationed care to our patients and robbed doctors in the process. These business folk came under the guise that they were here to 'do good,' to 'help us,' to create things like 'Health Maintenance Organizations' to prevent disease in our patients."

One of the easiest ways to make medicine more patient-centered is by allowing patients to enter information in their own medical records. At present, even though the medical record is all about the patient's medical history , most doctors and hospitals do not even allow patients to see their own records. I think this is ridiculous !

For example, in our own practise, after taking a history and formulating a diagnostic and treatment plan, I write this down ; and read it back to the patient, so that the patient knows exactly what's in their own medical record. I always make entries in front of the patient - and explain to them what I have written, so they know what's happening.

This simple practise has multiple benefits - for my patients and for me.

1. It empowers patients by involving them in their treatment. It shows them that I respect them and am willing to explain what is happening to them. It helps to demystify their medical treatment ; and they understand that medical terms are not Latin - they can make sense of them !

2. It ensures that I do not forget important medical details. If I do so inadvertently, my patients will correct me promptly ! This helps to reduce medical errors.

3. It helps in making sure that we are on the same page. Explaining the medical record is a great tool for improving doctor-patient communication and ensuring that we have the same priorities and are headed in the same direction.

4. It's a great way of risk management. Explaining the record to the patient is an effective way of documenting that the patient knows what's happening - and that the facts have been explained to him !

Most doctors are very good at getting their patients to follow their advice. ( The major difference between good doctors and bad doctors lies not in their ability to convince their patients, but in the quality of the advice they give. Good doctors give advice which benefits their patients; while bad doctors give advice which benefits themselves).

Doctors have learned that one of the best ways of persuading patients is by telling them stories - and many do this by describing similar cases they have treated successfully. Often the stories are embellished to make them more dramatic ( " I had a young man who came to me with chest pain just like yours . I did an angio, found he had a major block in his coronary; stented it; and now he plays tennis daily ! If he had come even a few days late, he'd most probably be dead by now "). Others will namedrop, to show you how high-profile their patients are.

Be careful when you hear these stories - they may not apply to you - and anecdotal case studies are of little value in modern evidence based medicine. Stories can be fun to listen to - but they are not very reliable, so take them with a pinch of salt !

Saturday, July 19, 2008

Survivorship A-Z: "To provide the practical information you need to thrive in the 'new normal' that exists after a life-changing diagnosis. Our information is modified when appropriate to specific conditions such as Cancer or HIV/AIDS. Our information can also be tailored for your life and situation through an Individual Action Plan.

Choose the help you need:

* Get the practical information you need for all parts of your life impacted by your diagnosis in whatever depth you want - including downloadable forms. * Personalize information to your disease, stage, social and economic situation with a free, one-of-a-kind Individual Action Plan. Your plan is computer-generated. It changes as your health, economic or personal situation changes. * Start your own personal Symptoms Diary to keep track of your symptoms. With a touch of a button, you receive an instantly readable graph to show your doctor. * Use our Health Plan Evaluator to help choose the health insurance policy that's best for you considering your health condition and your particular needs. If you are Uninsured, learn how to get the care you need - and how to obtain health insurance. * Use our interactive charts to help maximize your financial situation. Health expenses account for over 50% of bankruptcies - including people with insurance."

Josie King Foundation | Condition H: "UPMC Shadyside's Condition H model was created to address the needs of the patient and family in case of an emergency or when the patient is unable to get the attention of a healthcare provider in an emergency situation. The call provides our patients and families an avenue to call for immediate help when:

* they feel they are not receiving adequate medical attention; or * if they become concerned with what is happening.

When Condition H is called, a rapid response team arrives to the patient’s bedside within minutes."

This is a great idea ! Why should all Code Blues be called only by medical staff members ?

The Center for Patient Partnerships: "Patient advocates work alongside patients to help them make informed medical decisions, get the health care they need, and build strong partnerships with providers. Advocates also provide support to assist patients as they deal with medical, legal or financial uncertainty. Advocacy on behalf of patients has been practiced in some form by nurses, social workers, physicians, lawyers and others throughout the history of medicine."

Information Therapy (Ix) Blog: "When we talk about information therapy (Ix), we often drift into “evidence-based information” to help with some specific health condition.

That certainly is an important component of Ix, but it’s too limiting in many circumstances. When we talk about the “proactive delivery of the right information to the right person at the right time,” that has to encompass whatever the information needs of the consumer are.

What we know from talking with consumers–and from a variety of other research and projects–is that people have health- and health care-related information needs about so many things that have nothing to do with the best evidence-based health information.

* How do I find out if this procedure is covered by my insurance? * Who should I go see for this condition? * How do I get there? * What can people who have had this condition tell me about what it’s like to live with it?

The list of questions is virtually endless. The point is that information therapy refers to getting good information to people for whatever the consumer needs for his or her well-being and health/health care-related decision making."

Sunday, July 13, 2008

WHO | Patients for Patient Safety: "Patients for Patient Safety (PFPS), emphasizes the central role patients and consumers can play in efforts to improve the quality and safety of healthcare around the world.

Through the work of PFPS, the World Alliance for Patient Safety collaborates with a global network of patients, consumers, caregivers, and consumer organizations to support patient involvement in patient safety programmes both within countries and in the global programme of the Alliance.

The ultimate purpose is to improve health care safety in all health care settings throughout the world by involving consumers and patients as partners. The global network of Patients for Patient Safety Champions are passionate and courageous individuals who work in partnership with health professionals and policymakers across the world to identify problems, design solutions and implement change."

One of the commonest complaints patients have about doctors is that they do not provide them enough information about their medical problem. Everyone hates being kept in the dark, especially about such key issues as health and illness. This is why many patients turn to the internet, to find more information about their medical problem.

The good news is that there is a wealth of information available on the net , which means that no matter what you are looking for, you should be able to find it. The bonus is that most of it is free ! Also, since a lot of it is written for patients, it’s quite easy to understand; and some of it is reliable and updated.

However, many patients do get frustrated when looking for healthcare information. The kneejerk reflex when doing an internet search is to “google “ it ( www.google.com) – and while this can be a useful starting point, this can often cause a lot of problems. For one thing, there is too much information – and this information overload causes patients to get lost. They cannot separate the wheat from the chaff, and often end up reading unreliable or outdated medical information, as a result of which they get confused and frustrated . This also means that their end up upsetting their doctors, because they are misinformed.

Another risk is that some of the facts can be quite scary, and not all patients are willing to confront the truth or their own mortality; and because some of it is in technical jargon, it maybe incomprehensible. This is why many patients prefer not doing a search at all . They believe that a little knowledge is dangerous and they don’t want to become a “half-baked doctor”. Unfortunately, this means that they end up throwing out the baby with the bath-water.

Here’s a short and simple guide to help you find reliable information on the internet.

It’s important to get organised. Start first by identifying what the purpose of your search is.

Is it a simple search, where you just want to find out information about the side effects of the medications your doctor has put you on ? The internet is great for this – and it’s often just a question of typing in the generic name of the drug and scanning the results. However, your search could be far more complex. You may want to find out why your child has had fever for many days. Do you have adiagnosis ? Or is this still uncertain ? Write down the keywords which your doctor has used – even if this is in medical jargon you cannot understand.

You usually have 2 options to start your search. One option is to go to a general search engine, such as google, and look for information. The great thing about google is that it is easy to use , but because it is not very smart, this often means that you are inundated with a lot of irrelevant information you may need to wade through. There are also specialized health search engines such as Healia (.http://www.healia.com/healia/) which provide more focused results.

Don’t worry if you can’t make sense of the initial results. This is bound to happen because this is unfamiliar territory for you. Trust your intelligence and remember that the secret is repetition –you will get better with time, and this will help you get to the gold very quickly. If you cannot make sense of some of the medical terms, there are excellent medical dictionaries and encyclopedias online. My favourite is www.answers.com . Don’t get frustrated - think of yourself as a detective who is trying to unearth elusive clues !

What if you do not know what your diagnosis is ? A great site to find out what the diagnostic possibilities are is FreeMD at http://www.freemd.com. You just need to answer the basic questions, and the talking head will help you figure out what your diagnosis is. Another good site is Wrong Diagnosis at http://www.wrongdiagnosis.com

The biggest problem with a lot of these sites is that they are US-based. This means that most of the information applies to the US and you have to figure out what the Indian equivalents are. This does take some more time and energy, but hopefully Indian health websites such as TimesWellness( http://www.timeswellness.com) will provide more India-specific information soon.

What are some of the common problems you may face ? The biggest problem is that you may get too many results. Just because you get 1 million hits on google does not mean that you need to scan all of them ! Most of these sites will have the same information, so you are very unlikely to gain much by visiting more than 3-4sites. I usually open 4-5 windows and scan them quickly, to determine which seems the best. Fortunately, most of the best information is on the first page of your google search. You can also focus your search by providing more specific keywords.

What happens when you unearth conflicting information ?This can be quite a difficult situation, and it’s hard to know whom to trust. The trick is to check the publisher of the information. Is the website published by a reputed and trusted organization, such as the NHS, the US government or Mayo Clinic ? In this case, you know this information is trustworthy. Remember that anyone can publish a website, so don’t trust everything you read on the web. You need to verify and cross-check !

What can you do if you get stuck ? Simple – just ask for help ! If you have a teenager at home, ask them ! They are great with using the internet and can provide useful tips. Librarians can be a very useful source of guidance, and the HELP library provides a freeAsk-the-Librarian service at http://www.healthlibrary.com/information.html to help you get started on your search.

Remember that your internet search is just the starting point of your quest for knowledge. Your doctor is your guide and will be able to refer you to useful websites. Many good doctors these days have their own websites, and you can tap intothese if you need reliable information !

You can use the internet for a lot more than just finding health information.You can use it for: getting a second opinion; talking to your doctor ( virtual web visits) , so you don’t need to go to his clinic;finding hospitals and doctors which provide the services you need; storing and organizing your medical records; forming communities with others with a similar problem to find online support; and to shop for medical equipment and supplies. We’ll discuss these additional uses in the next article.

Ideal Medical Practices " What can we do to return the locus of control to our practices and ensureadequate compensation for our work? We have to redesign our practices tooptimize efficiency and show that we can not only deliver superb care but alsolower the total cost of health care. The “ideal medical practice” model canmove us closer to this goal."

Thursday, July 10, 2008

Medical Mistakes: Get a Patient Advocate | Healthy Living | Health.com Blog: "One simple way to lower your risk of turning into a statistic is to bring a family member or friend to act as your advocate. “When my mother goes into the hospital, I’m petrified, so I watch things quite closely,” says Peter Pronovost, MD, of Johns Hopkins University School of Medicine in Baltimore."

Patient story telling, and physicians adding to the story, may seem overly simplistic. But let us not forget the story of mankind and of medicine is nothing more than compilations of individual stories."

Are you visiting your health care clinician or pharmacist? It is important to be prepared. Create a personalized list of questions that you can take with you.

* Did your clinician give you a prescription? * Are you scheduled to have medical tests? * Did you recently receive a diagnosis? * Are you considering treatment for an illness or condition? * Did your clinician recently recommend surgery? * Are you choosing a health plan? * Are you choosing a clinician? * Are you choosing a hospital? * Are you choosing long-term care?"

In Other Words…Communicating When Naked: My Perspective as a Patient - Health Literacy: "Create your own medical record. As a health-literacy consultant, I sometimes speak to consumers about health communication. One recommendation I make is that people create their own notebooks with important medical information. But did I take my own advice? No, at least not until it felt like medical matters were way out of control. Creating my own medical record turned out to be one of the most important things I did."

"Questions Are the Answer" to helping patients understand their health: "The 'Questions Are the Answer' campaign builds on what patients and providers agree is important — that patients should be involved in their own healthcare. Involved patients tend to have better health outcomes, and asking questions is an important, though admittedly basic, way to be involved. 'Yes, it is straight forward. But people don't do it. This is a huge opportunity,' says Clancy."

Monday, July 07, 2008

1ST:INFORMATION THERAPY: This helps by making you smarterand also helps shield you against unnecessary overtesting, expensive medication and unnecessary hospitalization. PREVENTION IS ALWAYS BETTER THAN CURE..!!

2ND :EAT WITH YOUR BRAIN AND NOT YOUR PALATE ..!!

Fruits, vegetables and salads are harmless, so have them in wholesome quantities . Eat a wide variety of foods, and eat slowly, so you can enjoy your food and digest it well. “Junk Food” is junk - it only serves to pack in poor quality calories that just make you feel full.

3RD : RESOLVE TO HAVE A FIT BODY ..

“Exercise” doesn’t necessarily mean that you have to empty your pockets at Gyms and on Expensive treadmills only..! One of the best forms of Exercise is “Brisk Walking” and it is absolutely free of cost.. Please try to find time to do this simple activity for just half an hour a day. Obesity is a silent killer – and affects your self-esteem and your social status as well.

4TH :STOP ADDICTIONS – ALCOHOL AND SMOKING..

The easiest way to stop this addiction is never to start ! No matter how clever the marketing and how seductive the ads, these are poisons , which will kill you sooner or later. It’s not easy to kick the habit – but there are lots of tools to help you to do so, once you make up your mind !

5th :REMEMBER THAT STRESS IS YOUR OWN CREATION SO CREATE ONLY AS MUCH AS YOU CAN HANDLE..!!

STRESS is created in your mind – and arises when you either try to do something you can’t do or don’t do what you are supposed to ! There’s lots you can do to tame the stress, and prevent itfrom becoming distress ! Learn Yoga and Meditation and make sure you get enough sleep.

6th. CULTIVATE YOUR SPIRITUALITY . All of us are going to die some day - and being comfortable with your spirituality will help you come to terms with any illness - and with your death much more easily ! This way you do not have to treat death as an enemy and waste time and energy on futile end of life treatment.

7th. BUY A HEALTH INSURANCE POLICY . Being ill can be expensive - and taking out a health insurance policy can help to buffer the costs of being in hospital.

8TH : BE SAFETY CONSCIOUS ! Safety consciousness can help to prevent thousands of untimely deaths. Wear a helmet when you are on a bike ! Most accidents occur at home – and are the leading cause of death amongst toddlers. Be careful how you store your medicines; and take common sense precautions against fire and electrical hazards.

9th: KEEP YOUR COMMUNITY HEALTHY . It’s very hard to remain healthy if you live in a dirty environment. Dirt attracts pests and parasites, so you need to get together with the rest of your community to ensure that your surrounds are clean; you have a source of safe drinking water; and sewage can be disposed off securely.

10th: HAVE FUN ! Have lots of friends ! Not surprisingly, many studies have confirmed that happy people with extensive social networks live longer than loners.

Sunday, July 06, 2008

All of us pine for the family doctor of yore – the friendly old gentlemen who would come home and treat us over a cup of coffee. We all want our doctor to be a friend, philosopher and guide – a trusted adviser, who will guide us when we are sick and help us to become better.

Unfortunately, the sad truth is that this type of Marcus Welby is now a dying breed. Given the fact that we move much more from town to town; that HMOs dictate whom we can see and who we cannot; and that medicine has become much more specialized , few of us have the luxury of having our personal physician and are rarely able to establish a long-term relationship with our doctor.

While doctors of an older generation looked down on advertising, today marketing is a fact of life for hospitals, doctors and clinics. For-profit hospitals are corporate entities who need to earn money for their share-holders, and spend a sizeable chunk on advertising. Doctors, who need to compete, also do the same, which means that many patients now feel that medicine has become much more commercial and that doctors are often trying to sell them on tests, procedures and operations.

So has the doctor just become a high-powered salesman who is peddling his wares ?Is your heart surgeon advising bypass surgery, even if you don’t need it, because it helps him to make a quick buck ? How can you protect yourself from overtesting and overtreatment ? Can you trust your doctor to be professional and do what’s in your best interests, rather than in his ? Does he have a hidden agenda ?

It’s a fact that doctors in private practice need to sell to survive. The key question is - what is he selling ? Is he selling good advise ( which all of us are happy to pay for !) Or is he pushing the procedures he performs ? And how can you tell the difference ?

This isa hard question to answer – but one of the most important ones you will have to tackle when you fall ill ! Which doctor can you trust ? and why ? A wrong decision can prove to be extremely expensive !

So how do you know if you can trust your doctor ? All of us do our “due diligence” when selecting our doctor , but for many of us, this is a haphazard , hit and miss procedure, based more on word of mouth referrals, rather than a systematic analysis. Your doctor should earn your trust – and he can do this by being generous with his knowledge; showing you that he cares; respecting your time; and fulfilling his promises. The hallmark of doctors who have been elevated to the status of being treated as trusted advisors by their patients is that the doctor places a higher value on maintaining and preserving the doctor-patient relationship itself , rather than on the outcome of the current consultation.

Establishing a history of reliability is one way to build trust. For example, if your doctor tells you he is going to call with lab results, does he do so ? If he does this the first time , this shows that you can count on him. If he does it consistently, this will build trust. This is why senior doctors value their reputation so much – it is built on the foundation of a lifetime of hard work – and even though it is intangible, it represents the fact that patients have trust in them.

Credibility = can you trust what your doctor says ?Reliability = can you trust his actions, confident that you will act honorably ?Intimacy = are you comfortable discussing your feelings and emotions with him?Self-orientation = can you trust his motives, knowing that he cares about you , and will act in your best interests ?

In the final analysis, please trust your gut feelings ! If your doctor promises too much; hides facts from you; cannot be trusted to respond to your calls; does not answer your questions; does not respect your time by making you wait for interminable periods; or treats certain patients selectively as VIPs , while the rest are short-changed, you should smell a rat !

One of the problems with any healthcare system anywhere in the world is that there are too few doctors and too many patients. This is as true in the US as it is in India. This means that patients have to suffer . Not only are there long waiting lists, they get to spend only a few minutes with their doctor during their clinical encounters. This makes for unhappy patients – who will often vent their anger on the doctor if there is a mishap or bad outcome.

The standard kneejerk reflex to this problem is train more doctors. If we have 1 doctor for every 1000 patients ( or whatever the magic number is, depending upon the author), all our problems will be solved ! Actually, this is not true. Churning out more doctors just ends up creating more clinical work, because doctors create their own demand ! Also, even if you do have more doctors, most of them will end up working in large cities, so that the poorer neighborhoods and the villages still remain underserved. We need to understand that we cannot solve this problem by regulating the supply of doctors – we need to look for alternative solutions !

The Aravind group of Eyecare Hospitals has taken an innovative approach. They realized that a lot of what the doctor does can be done by someone else, so they have taught non-doctors to perform the doctor’s tasks. Thus, routine clinical procedures , such as checking the intraocular pressure, which are usually performed by ophthalmologists in other hospitals ) are now done by trained assistants, thus freeing up the doctor to focus on his patients.

I think we can go one step further – and get the patients to take on many of the roles which the doctor plays today . Now this does not mean that I think we should teach patients how to do surgery !

Let me explain. One of the key tasks of a doctor (and a very time consuming one, if done properly) , is taking a medical history, where he listens to the patient and tries to figure out what the medical problem is. Traditionally, this history is taken at the clinic by the doctor; and in busy clinics, the medical history is taken by an assistant andthen reviewed by the doctor.

This is not the best model, because often the patient forgets important information during the stress of the consultation; or may not have access to important medical details or records ,because he has forgotten to bring them.

Why not allow patients to fill in their medical history online, at home, before coming to theclinic ? We do this routinely in our practice. Our patients have to fill out a structured form at www.drmalpani.com/malpaniform.htm - which ensures they will provide me with all the information I need to formulate the right treatment plan for them.

A very clever program called Instant Medical History (www.medicalhistory.com) allows patients to take their own history at home ! Branching logic enables patients to progress quickly through adjustable questionnaires from an extensive medical knowledgebase and provides the patient and the doctor with a very well organized and complete history – thus saving the doctor a lot of time and ensuring that no information is left out. Equipped with this, the doctor can then confirm the important medical features and get on with the clinical examination ! You can watch a video of how this works at http://www.medicalhistory.com/videos/amazingchartsinterface.swf

We can even go one step further ! Most patients have simple problems for which they do not even need to visit a doctor. Many problems are self-limited; or will get better on their own. All the doctor needs to provide is some hand-holding and reassurance – and a lot of the time, this does not need a trip to the clinic !

Does the patient really need a face to face visit ? Can the problem be resolved by a phone call ? email ? a web visit ? This allows many more patients to make much more efficient use of the doctor’s time ! But what if the problem is serious and is missed because the patient did not visit the doctor ? This isa valid concern ; and the good news is that clever triage programs can help to ensure that patients can manage simple problems for themselves with self-care . An excellent example of such a free program is available at www.freemd.com !

Just like supermarkets make their customers do all the work ( select their products and put them in the cart), clever technology can allow patients to do a lot of the routine work which doctors do today. Not only will this free up the doctor’s time; it will also give patients much more control over their own medical care; and allow doctors to concentrate on key clinical tasks. Patients are the largest untapped healthcare resource – let’s make the most of them !

My wife, Dr Anjali, and I work together in our IVF clinic. Sometimes our friends wonder how we can manage to live together and work together ! Don’t you get fed up of being with each other all the time ? is a common question.

I think we make a great team, as we have complementary roles to play. For example, even though we work together taking care of the same patients, we have a clear demarcation of our professional roles. Anjali does the scans and the egg collections – while I do the consultations and the lab work. This way, we both get to do what we like and are good at , which makes this a winning combination. We get a chance to focus on our core strengths and don’t have to do the stuff we don’t like doing or are not good at doing.

Our patients like this too. Wives are often much more comfortable talking to Anjali, while the men find it easier to talk to me. Also, some patients prefer her personality – while others prefer mine ( I must admit more prefer hers to mine !) This allows us to establish a rapport much more easily.

Since we work as a team, patients have access to an instant second opinion – for no extra charge ! Also, when we come across complex problems, complications, or difficult patients, we act as a sounding board for each other – and two heads are better than one.

Are there any downsides ? Yes, there are ! Not only do we argue about family issues, we also end up arguing about patients. While this is in the patient’s best interests, it sometimes does confuse patients who are not sure why we cannot agree. The more mature patients understand the importance of our disagreement. Medicine is not an exact science, and there will always be room for differences of opinion. Talking to both of us ( especially when we disagree) gives patients a much better perspective on their problem.

It’s taken me a long time to learn this, but Anjali’s intuition is far better than mine; as are her people skills. Now that I acknowledge this, I am much less likely to be pig-headed – and am more likely to agree she is right ( she usually is, but I realize this much sooner these days).I think we form a balanced team – and since we are both on the same side, we have a very stable clinical practice – and a happy marriage !

It’s all very well to advise patients to become empowered and to take an active interest in their treatment. However many patients complain that if they ask their doctor questions , the doctor gets irritated and often puts them in their place by asking them – “Are you the doctor ? “ or – “Just leave everything up to me - I am the expert. “

So what is the poor patient supposed to do ?

Firstly, try to be empathetic and look at things from your doctor’s point of view. He has lots of patients to see; a limited amount of time; and will do his best to maximize his efficiency and his income by trying to see as many patients as possible.

The trick is not to get scared and stop asking questions , but to learn how to ask questions and which questions to ask.

Here are some suggestions you might find helpful.

1.Do your homework . Be prepared.

2.Tried to find answers for your questions yourself by doing a google search

3.Ask focused questions, which relate to your specific problem

Remember that both you and your doctor have the same interests at heart – both of you want you to get better. Work as partners - you are both on the same side !

It’s a good idea to write your questions down. If you can show him that you have tried to answer them for yourself, he will be much happier to answer the ones which have stumped you !

It’s important to not waste your doctor’s time by asking irrelevant questions. These will often end up irritating your doctor, and you will lose his good will.

Try to be assertive – but not aggressive. It’s not hard to do this, if you are respectful; and ask your doctor’s permission to ask him questions ! If it's not convenient for him to answer your questions in this visit, ask him if you can email him the questions; or get another appointment, when he has more time.

A good doctor understands that it's in his best interests to resolve a patient's doubts and questions - and will do his best to do so.

If , inspite of your best efforts , your doctor is still upset when you ask questions, then this justmeans that he is not the right doctor for you - or that you are not the right patient for him. Find another doctor !

As an IVF specialist, I am amazed by how often gynecologists will "hang on" to their infertile patients. Some of them keep on doing IUIs again and again - while others will do useless procedures such as laparoscopy or D&C or myomectomy.

Not only does this waste valuable time, it often means that patients get fed up and frustrated ; and lose confidence in doctors and in medical treatment, which means they often refuse to do IVF. This is a major tragedy, because they have deprived themselves of their best shot at getting pregnant, as a result of their gynecologist's making them waste their money and energy on futile treatment.

I am sure some of them tell patients not to do IVF with the best of intentions - because they do not want patients to waste their money on expensive treatment which may have a low chance of success. While I appreciate this attitude, I feel it is unfair and incorrect of gynecologists to make this decision on behalf of their patients. It's best to let patients decide for themselves. Yes, IVF is a financial risk - but it's the patient who should decide if she wants to take this risk or not !

Patients should never have any regrets that they left any stone unturned and didn't give themselves the best shot at fertility treatment. While the outcome of any treatment is always uncertain, taking the right treatment at a world-class clinic can give them peace of mind , and this can be invaluable ! IVF treatment can be expensive, but a baby is priceless.

A good gynecologist will explain all the options to his patient and will be willing to offer referrals to IVF clinics - and to adoption agencies as well. These are not mutually exclusive options - and the patient should be encouraged to explore all of them !

Saturday, July 05, 2008

Health 2.0 Accelerator - What is the Health 2.0 Accelerator?: "Healthcare companies, whether they are small technology start-ups or established healthcare organizations, are endeavoring to create value by utilizing the internet to streamline information flows. Their ultimate goal is to package information in a way that helps consumers manage their health more effectively. However, companies are encountering time-consuming and expensive challenges presented by the myriad of standards activities and interoperability strategies clouding the industry's innovative progress. The Health 2.0 Accelerator is a collaborative of these healthcare companies whose goal is to accelerate value creation that can transform the industry by:

Patients want PHRs ! " Four in 5 U.S. adults believe that online PHRs would be beneficial in managing their health and health care.

• Nearly half the public expresses some interest in using one.• Yet less than 3 percent of the general adult population has an electronic PHR today.• Among those not interested, concern for privacy is the most frequently cited reason why.• Majorities of 87 percent to 92 percent say six key privacy practices are factors in their decision touse an online PHR.• More than 90 percent said their express agreement should be required for each use of theironline health information.• More than 75 percent said each of four possible policy enforcement mechanisms would beeffective."

A friend was doing a search on the causes of high bilirubin levels in adults. He found a lot of garbage – mostly bulletin board postings and anecdotal case reports. He was also swamped by a lot of irrelevant results about neonatal jaundice.

I repeated the search using the same search engine, but using a better keyword – “ hyperbilirubinemia “ – and this improved the results dramatically.

Searching for “ adult hyperbilirubinemia differential diagnosis “ gave the best results . The problem was solved – and took just a few minutes of an expert’s time, and saved the user hours of frustration !

1. Health and medical information is the No 2 reason people use search engines2. Many users are frustrated with the results of the searches they get

There are two groups of reasons for this.

1. The search engines. These are not clever enough to separate the wheat from the chaff, which means they deliver too many results, many of which are poor quality; or irrelevant.2. The searchers. Many are naïve and don’t know how to do a searchproperly . They make spelling errors; are unfamiliar with medical terms; and cannot evaluate the quality of the information they find.

This means there is a lot of searching – but very little finding !

What do users want when they do a search ?

They want results which are instant; reliable; relevant; understandable – and free ! While present search engines offer instant searches which are free, they often fail to provide reliable and relevant results, because Garbage In is Garbage Out.

So how can we improve the quality of health searches ? Most of the focus so far has been on making the search engines better. One approach would be to automatically provide the search engine with better inputs. For example, searches could be personalized using context sensitive information from the user’s a personal health record ( PHR) .If the user is searching for diabetes, is it a 12 year old ( in which case you should be looking for juvenile diabetes); or a 60 year old ? It is this ability to provide context that we pay doctors so much money. They specialize in being able to quickly apply a subset of their medical knowledgebase to individual patients, based on : the patient; and their clinical experience.

We need to start by trying to create a taxonomy of health searches . I don’t think this has been done. It would be easy to do – and would provide interesting insights !For example, health searches can be classified as Pre Diagnosis/ Post diagnosis Simple/ complex Well defined/ poorly defined With / without spelling mistakes With / without medical terms

It would also help to know why the search was being done. Is the user looking for specific information and just needs background knowledge of a particular illness ? Or is this a comprehensive search to look for elusive nuggets of information ? This first step will give us a better idea of what terms people use today to find information; and why.

Give the fact that there is so much information on the web, this means that it’s virtually a certainty that the information the user wants is there on the web – it’s just that the user cannot get to it. This can be very frustrating.

The holy grail would be to use a semantic search engine which had access to information from the searcher’s personal health record ( PHR ), so that the information is customized and filtered) ; and then to use artificial intelligence to display the latest , most uptodate information only from selected reliable websites.

Till we reach this stage, can we do anything to improve the user who is doing the searching ? One way of doing this would be to provide tutorials or help functions, but the fact remains that most users do not use these well at all.

I am interested in exploring whether using a human intermediary ( a doctor or nurse or librarian in India, for example) to answer questions would help improve searches.

The model would be to charge a micro-fee ( say $ 1 for a search) ; guarantee an answer( to questions selected by the infomediary only) in 24 hours ; and allow the infomediary to select only the easy questions to answer ( those which were well-formed and well-defined). This is likely to help a significant chunk of users ( who only need some hand-holding) .

The expert human infomediary has the ability to use the search engine intelligently to provide much better results ! For example, he knows the importance of iteration to refine results ; and how to evaluate the quality of the websites found. This can be very cost effective, because these answers not only save time ; they also provide reliable information ! He also knows when to search the “deep web” ; what specialized databases can be tapped; and which searches are unlikely to provide useful results !

Searches done by the infomediary could also serve to provide feedback to the search engine algorithms, so they could be continually refined and polished.

Such a market economy of choice, quality, and price obviously will work only with a limited population set -- those of the educated middle class. While this might seem like pampering an already well-off segment, the idea is to let market forces work for one segment that does not greatly need government support and thereby relieve it of responsibilities -- and release funds in the process -- to focus on the vulnerable poor.

It is important to note why India might entertain such an idea in the first place: funding for nationwide health out of general revenues have been miserably inept and its efforts largely bypassed by every segment of society. Social insurance of a sort barely exists outside of a small privileged few falling within the purview of the Employees State Insurance Scheme (ESIS); and private insurance, left unchecked, might just begin to replicate the problems one experiences in the US. In the meantime, the out-of-pocket regime flourishes with serious repercussions to the patients and their families. In this scenario, only the provider and manufacturer segments gain. A supermarket of quality providers rated by neutral third parties that enables consumer choice in service packages and price would appear to be just what the doctor ordered."

The Indian healthcare industry is a huge opportunity and hopefully we will learn from the mistakes the US did, and do a better job !

“You find a lot of asymptomatic disease,” said John O. Goodman, a business consultant to cardiologists. “It will put more patients in the cath lab” — medical shorthand for a cardiac catheterization laboratory, where conventional angiograms and stenting procedures take place.

Ms. Mitchell said cardiologists simply practice medicine the way the health system rewards them to. Given the opportunity to recommend a test for which they will make money, the doctors will.